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such cases out of a total of 3,425 treated during the last fiscal year. The appropriation for all was about $900,000, so that an estimate of $415,000 may be made for crippled children. This is exclusive of capital invested. As stated before, this number of crippled children treated is relatively very high and indicates the law must be very vigorously enforced.
It seems to a limited degree that the Iowa plan represents a combination of the principles found in Minnesota and Ohio. It differs from Ohio chiefly in being a centralized plan, so far as treatment is concerned, and in that it greatly neglects the education of crippled children except during the period of their hospitalization. Great success in finding crippled children seems evident.
Massachusetts followed the lead of Minnesota and established a state orthopedic hospital, convalescent home, and special school. Hospital facilities for one-hundred patients provide medical, surgical, and nursing care. In addition to the standard public school curriculum, music, domestic science, cobbling, sewing, and other various industrial and vocational preparatory subjects are taught. Indigent children are admitted directly on a voluntary basis upon application of parents and guardians. A number of the admittances are private, or "pay" patients. When parents are unable to pay, the charges are referred to the county or city in which the child previously resided. The hospital and school have an average attendance of three hundred. The cost is approximately $175,000 for 360 patients, as estimated by the state department of public welfare. We have no figures on the capital invested.
Probably the first state census of cripples was made in Massachusetts. She has a well-distributed number of private institutions and agencies caring for crippled children. These represent a unit of the Shriners' chain of hospitals, orthopedic departments in general hospitals, institutions for incurables and custodial cases, as well as for convalescents, agencies for after-care, and also research, and finally for various types of education. Some of these are related to the state government. "Institutional care is splendidly developed in this state. . . . . Inasmuch as the entire . . . . solution of this problem has been developed along institutional lines, and inasmuch as almost every one of these institutions possesses well-equipped schools, special classes are not greatly needed. . . .
New York. It is thought by some that New York State now represents a development which is most typical of the best sentiment of the country on the subject of state programs for crippled children. While she has had a state institution since 1900, a recent survey made by a special state commission has led to new legislation establishing a program largely independent of the institution, although including it in the major purpose to coordinate all efforts, public and private.
This act provides a statutory definition of a physically handicapped child, and an advisory commission for physically handicapped persons which, in addition to rehabilitating handicapped persons over fourteen years of age, is "to
stimulate all private and public efforts designed to relieve, care for, cure, or educate physically handicapped children, and to coordinate such efforts with the work and functions of governmental agencies." This commission is also "to maintain a register of physically handicapped children [and] to use all means and measures necessary to meet adequately the physical and educational needs of such children, as provided by law."
The state will seek out all crippled children, from birth to eighteen years of age, insist on their being adequately cared for, and furnish the costs of care, relief, and education when parents, guardians, and local communities fail to do so as required by law. Many leaders in the work in New York State believe this will, in a reasonable length of time, practically revolutionize the work of the state relating to cripples.
HEALTH ACTIVITIES OF CHILD CARING AGENCIES
EXAMINATIONS ON ADMISSION
Arlene Bauer, D.A. Blodgett Home for Children, Grand Rapids
The entrance examination is an old but still ever new subject as the advance of medical science and mental hygiene steadily renders it more complete. The opportunity it gives the child for far-reaching physical betterment often overbalances the seriousness of his removal from home.
Statistics show that a child is actually a liability until twenty years of age, rendering the establishment of a firm foundation of health through a preventive program of real social and economic value.
An entrance examination properly begins in the securing of a complete history of the family in so far as it affects the physical and mental health of the child, also the family's health habits, as a measure of its effect on his present condition as well as upon the cooperation one can expect upon his return.
Efficiency and cooperation through interest of the physician is most important in his selection, also the addition of ear, eye, nose, and throat specialist, if possible, to examine expertly the eyes and ears that, unknowingly defective, have so often wronged a child through a false terminology of dulness and even mental deficiency.
The routine given every child should consist of Wasserman, smear, urinalysis, nose and throat cultured Von Pirquet, vaccination, and toxin anti-toxin, the latter harmless in their reaction after the sixth month.
Points of physical history including birth, feeding, development, previous illness, operations, immunization, hygiene, and habits, as well as physical examination consisting of general nutrition, heart, chest, abdomen, genitals, muscles, bones, joints, glands, skin, and nervous system were discussed with especial emphasis on tonsils and their far-reaching causes for ill health; also
teeth, and the fallacy of lack of care under the assurance that they will soon fall out, while in the meantime the child may be gathering infection or because of tenderness improperly masticating, resulting in lowered resistance or the beginning of a serious underweight condition; thyroid and its important relation to the building of bone and fat; and last, malnutrition with its varied serious effects and treatment. Dr. Emerson, of Columbia University, states that 90 per cent of children are underweight from physical defects, especially naso-pharyngeal obstructions, lack of home and personal control, overfatigue, faulty food habits and improper food, and poor hygiene.
In conclusion, I emphatically state that this valuable information is worthless unless used, not only until the child is as physically and mentally perfect as it is possible to make him, as thoroughly educated in health habits as his mentality permits him to become, but until this knowledge is so thoroughly disseminated in his home as to establish proper health habits and bring about a recognition of the need of periodic health examinations for the entire family. Only thus have we actually insured his health and given our organization the right to carry on child welfare work.
CONTINUOUS HEALTH SUPERVISION
Mary E. Murphy, Director, Elizabeth McCormick
The title of this discussion indicates a different point of view on the care of children from that familiar to most of us a few years ago. It is distinct from the attitude with which a child caring agency brings to the attention of the hospital or dispensary the physical needs of children when symptoms of abnormality have already appeared. Continuous health supervision means a program of regular checking on the condition of children so that a healthful condition may be maintained or deviations from normal may be noted and corrected.
It is presupposed that the point of departure is the normal child, and that the program of health supervision is organized with a view to arriving at this goal of normal childhood.
Of course, a fundamental in this continuous health supervision is the physical examination, and with this distinct health point of view health supervision should provide a type of physical examination which not only notes real defects, but notes also such deviations from the normal as may have a direct influence upon the child's health. Such an examination can be made only by a physician who is familiar with the characteristics and the standards of development of normal children, and who also regards as important the whole program of the child in its relation to this physical development.
As an example of this type of thing, let me quote from the findings and recommendations made by the physician in connection with the examinations of
children in some of the work which we are doing in Chicago. Our work in this connection has included cooperation with United Charities in the continuous health supervision of their allowance families, and with the juvenile court in connection with the children of pensioned mothers. It is also included active cooperation with the Day Nursery Association in health supervision in regard to day nurseries.
In the case of Rose A. the findings were as follows: three carious teeth; tonsils large and cryptic; anterior cervical glands; nutrition fair. The recommendations were: dental care; watch throat; more milk; cereal for breakfast; stop tea and coffee; sleep with windows open.
It is evident that such notations on the part of the physician indicate that from his point of view a knowledge of the program relating to diet, sleep, fresh air, and exercise is an important factor in the diagnosis, and the correction of details in the program essential to the proper care of the case. Since this is true, it seems highly desirable that as a factor in this continuous health supervision the mother should be present at the physical examination, since it provides a most excellent means of education for her in the care of her child. This standard once established in her mind will then be re-emphasized by the nutrition worker or nurse, who follows through on the suggestions made by the physician.
Besides the first examination with its complete record of the social history, stock-taking of the habits of the child and of the family, and thorough physical history, there should be periodic examinations, which will probably take far less time, to indicate whether corrections have been made and whether progress is being made. Since it is now generally conceded that the growth record, especially relating to weight and height, is an important index of the child's physical condition, no program of health supervision can be considered complete which does not note regularly growth progress. A continuous record of a child with reference to weight and height should be a part of the physical record, and failure to make normal progress deserves attention.
This type of supervision, which is aiming at the normal child, depends upon very complete cooperation of all individuals who touch the life of the child. The child itself, of course, must be interested; the mother must cooperate on the program suggested; the physician's contribution has already been noted, and the nutrition worker or nurse provides the educational stimulus to both child and mother to carry out the suggestions. In addition, the social worker making contact with the family must be in spirit a health worker who cooperates closely with the physician and nutrition worker in re-emphasizing to the mother in the home the value of the advice given.
Our method in working with the agencies already mentioned is not to duplicate social visits to the home, but to expect the mother to attend the monthly or weekly meetings with the children. In the majority of cases the social worker is also present. If she is not, the nutrition worker and the social worker later communicate in regard to the essentials in the program to be followed
out, and the social worker then makes the necessary contact with the family. For the family agency, health supervision includes not merely the child whose condition indicates the need of special attention, but a regular health inventory of the entire child population.
THE USE OF CENTRAL CLINICS FOR CHILD
Alice H. Walker, Chief, Social Service Department,
Wide variations are found in the policies of child caring agencies regarding the most effective and economical plan of providing physical examination and medical supervision for their wards. The establishment of a small clinic within the department seems to be the most common plan. While highly commendable if no better service can be obtained, such a clinic is wholly inadequate when compared with the well-organized out-patient department of a hospital, made up of eighteen or twenty clinics representing all branches of medical service, and with the most complete modern equipment providing for all patients scientific examination and skilled treatment.
Outstanding physicians of recognized ability and wide experience are in charge of the clinics. The entire dispensary service is correlated, physician consulting with physician, and with a central record system assembling all records, laboratory and X-ray reports in one folder, this unified study passing finally into the hands of one physician for interpretation, final diagnosis, and recommendation for treatment. The facilities for making this study possible are under one roof, with hospital beds at hand for the acutely ill or for those who should remain under observation. The appointment system insures for each person sufficient time for an unhurried, complete examination.
It is extremely difficult to obtain the right type of well-trained, progressive physician to serve in an independent clinic, since hospital connection is of such vital importance to him. Furthermore, few physicians working alone in a meagerly equipped clinic, without X-ray, laboratory facilities, or opportunity for consultation, are competent to make an accurate diagnosis of illness in the early preventable or readily remedial stages, particularly if the symptoms are somewhat obscure.
Nor should the examination cover the mere physical condition alone. For the child caring agency it is essential that the personality of the child in the light of his past history and his present mental and social make-up should be studied if he is to be placed in the community to best advantage. A psychological study is particularly imperative for the difficult child who presents a behavior problem, in order that wise social treatment and proper community adjustment may be effected.